E.D nurses "set up to fail"
- page 3

Hi, I'm currently a nursing student about to graduate in May (2012). I am working as a nurse intern in a level 1 trauma hospital and got the chance to work in the E.D the other night. I loved the... Read More

I think that standard of care is silly. Using such cookbook medicine means that patients who don't have pneumonia will get antibiotics unneccessarily. And where are the MDs? You mean to tell me APRNs and PAs are taking the potentially critical patients? That scares me. But, that is beyond your control.

Point is, using one anecdotal situation makes your argument weak. *Especially* if it wasn't busy in the ED that night. This sounds like someone who would struggle no matter what environment they were in.

If you think new grads don't belong in the ED, that's fine. You're entitled to think that. However, I think it depends on the new grad, the kind of orientation they receive, and the type of ED they're working in (staffing levels, average daily census, number of beds, trauma designation, orientation length and quality, etc.). There are lots of new grads who are very sharp and catch on very quickly, and who know whey they're in over their head and when to ask for help. This one single example doesn't convince me that new grads in the ED are set up to fail.

The antibiotic prescribed needs to be started "door to dose," within 4 hours of arrival at the hospital. The timing of initial therapy is crucial. Data have shown that early treatment reduces mortality (This should have been one of her top priorities).

Your information is a little out of date. CMS & JCAHO relaxed the antibiotic initiation standard for community-acquired pneumonia from 4 hours to 6 hours in 2007. The standard itself remains controversial.

I think that standard of care is silly. Using such cookbook medicine means that patients who don't have pneumonia will get antibiotics unneccessarily.

I guess it is my hospital policy for 4 hours, either way my opinion is to start quickly when ordered stat.

You are right, some nurses thrive in the ER. I did when I graduated from nursing school. My problem with the new grads in the ER is very recent and maybe it is my state/geographical area, but I am finding that new grads are applying for every position that is available no matter what specialty or how they did in school. A few weeks ago a newer nurse, maybe was in ED about 6 months to a year didn't understand the heparin protocol order set on the MAR. She sent patient to me on a med-surg tele floor without heparin drip, oops. I work in another ER at another hospital and the manager will not hire new grads. I just find recently that I am writing up a lot of incident reports on emergency department that I didn't use to write up.

I am not going to sit here and write a diatribe against every new nurse that is entering the field, I love working with new nurses. I like answering their questions and helping them perform procedures for the first time sometimes on a real person. The other day we had an excellent new grad on the floor that picked up on a minor stroke with awesome assessment skills and had support around patient in a flash, probably saved this patient's brain function.

To the OP make sure when you start applying for new grad positions in the ED they will give you adequate mentors and enough time on orientation.

Thanks, interesting. I have read that most recent update and it says "Evidence shows better outcomes for administration times less than four hours. " I never came across that second article in my practice and I am always hoping to learn something new so I appreciate your kindness in posting that link.

My initial point was if the practitioner orders a stat drug, has made a diagnosis, waiting 6 hours is ridiculous and a nurse regardless of their experience should learn to prioritize better or learn to ask for help if they are sinking. I have always come across this website but never joined until recently because people can be so rude during a conversation, I appreciate the information you provided. My intentions of joining was to try and have conversations with peers and learn things. Instead I am called a liar for expressing something that I thought was poor practice when giving advice to someone seeking experienced folks.

I think it's important to note that the JC and CMS standards are for CAP. Some institutions apply them to *all* patients in respiratory distress in order to increase their compliance. In doing so, patients that don't need antibiotics are getting them, which contributes to antibiotic resistance. This is what I find silly.

I find it hard to believe that the antibiotic order was six hours old, if the patient was in the ED for six hours. It just doesn't make any sense. Nor does it make sense that the midlevels meet all the ambulances at the door. Am I calling you a liar? No. You put that word in my mouth. I'm just pointing out things that don't make sense to me.

Based only on my own development as a nurse the ER was way, way, WAY too much for me as a new grad. I might have managed in urgent care, but I wouldn't have learned as much as I did working on the floor. Even 6-7 years into my career I seriously had no idea how much I didn't know, and it was better for me and the patients to get more critical care experience. Granted, that could have happened in a mentoring ER situation, but new grads, be careful. Just emotionally, at 19, I wasn't ready to deal with the ER situations.

About your prof's statement, that we are set up to fail, my initial reaction was that we get the ICU level patients, (and a lot of our med/surg folk are ICU level for the first hour or so.) but don't get ICU staffing. So if I get 4 level 2 patients at 30 min intervals, and they all need multiple interventions and ongoing assessments, I'd better know by just looking who is having the real MI, and who has gas and anxiety. We can get called into a trauma, but we still have 3 other patients. Our coworkers will help, but the ultimate responsibility stays with the assigned RN, at least in my ER.

I recently came out of a trauma room and did a quick peek around at my other people. My coworkers had checked that they got meds and ordered tests, but no one had gotten fed, and someone who had come back from Xray was still on the portable tank. The tank read empty, but there was still gas coming out, so she was probably 5min from going dry. I was once in with an 80yo who was going in and out of Vtach for a couple hours. You cannot physically leave the room if you have someone like that, but I was still assigned other patients. Yes, you can do written follow up to your manager, but once you accept report those people are yours, unless you can report off to someone else. When you accept report in the ER you have no way of knowing what will come next, and no way to dump your other patients if one goes south.

i couldnt agree with you more!!
i am a new grad in the ED (i am just in my 3rd week now)
Luckily the newgrad program that I am on allows me to have 6 weeks orientation with a preceptor (an amazing nurse-- i am very lucky!) so i am not completely thrown into the deep end on my own... i recommend finding out how long of an orientation you get because i really think it is crucial. I am slowly learning how to handle 2-5 patient loads. All of the staff have been welcoming and extremely supportive given the chaotic (organized) environment!

I have had previous experience as an EMT which was a HUGE help.

My advice to you as a student is don't just stand and observe thinking that you will do it next time... just get into it!! Ask to do things.. ask other staff if they need help (if you have time to spare of course)

Though this is not a floor vs. ED thread ... I find it interesting that you pin deficiencies in physician orders on the nurse. Many a time when giving report I have found myself saying, yes, that really is his blood sugar ... that's why he's being admitted. If it was a fast fix, we'd have done it and discharged him.

Back to the regularly scheduled thread ...

Altra, I thought the exact same thing when I read that post. If there were that many issues with that pt at the time of admission then the ED doc is seriously incompetent. On the other hand, I would also expect that the ED RN should be competent enough to question the pt's condition and have good answers ready for the receiving RN if there are any, and if not, advocate for the pt and have the doc address the issues of concern.